Maternal-Fetal Medicine Practice Questions

Q: A 24-year-old patient presents at 18 weeks of pregnancy with a previous history of a child with Down syndrome. What is the most appropriate next step?

Amniocentesis. ### Explanation **1. Why Amniocentesis is the Correct Answer:** The patient is currently at **18 weeks of gestation**, which falls within the ideal window for **Amniocentesis (typically performed between 15–20 weeks)**. Since she has a high-risk history (a previous child with Down syndrome), she requires a **diagnostic test** rather than a screening test to confirm the fetal karyotype. Amniocentesis is the gold-standard diagnostic procedure for chromosomal analysis at this gestational age. **2. Why Other Options are Incorrect:** * **A. Triple Test:** This is a screening test (measuring AFP, hCG, and uE3). In a patient with a prior history of aneuploidy, diagnostic testing is preferred over screening because screening only provides a probability, not a definitive diagnosis. * **B. Chorionic Villous Biopsy (CVS):** While CVS is a diagnostic test, it is performed between **10–13 weeks**. At 18 weeks, the placenta is more developed, and the procedure is no longer the standard of care compared to the safer amniocentesis. * **D. Cordocentesis:** Also known as Percutaneous Umbilical Blood Sampling (PUBS), this is usually performed **after 18–20 weeks**. However, it carries a higher risk of fetal loss (1–2%) and is generally reserved for cases where rapid karyotyping is needed or when amniocentesis results are inconclusive. **3. Clinical Pearls for NEET-PG:** * **Diagnostic vs. Screening:** Always check the gestational age first. * **10–13 weeks:** CVS (Diagnostic) or Combined Test (Screening). * **15–20 weeks:** Amniocentesis (Diagnostic) or Quadruple Test (Screening). * **Risk of Fetal Loss:** Amniocentesis has a lower procedure-related risk (~0.5%) compared to CVS (~1%). * **Most Common Aneuploidy:** Down Syndrome (Trisomy 21). The recurrence risk after one affected child is approximately 1% or the age-specific risk, whichever is higher.

Q: A 32-year-old female presents with 8 weeks of amenorrhea, signs of shock, and a past medical history of tuberculosis. What is the most likely diagnosis?

Ruptured ectopic pregnancy. **Explanation:** The clinical presentation of **amenorrhea (8 weeks)** followed by **signs of shock** (hypotension, tachycardia, pallor) in a reproductive-age woman is a classic "spotter" for a **ruptured ectopic pregnancy** until proven otherwise. **Why Option A is correct:** The key diagnostic clue here is the **history of tuberculosis (TB)**. In endemic regions like India, pelvic tuberculosis is a leading cause of chronic salpingitis. This leads to tubal scarring, distorted anatomy, and ciliary dysfunction. When the fallopian tube is damaged but not completely occluded, it allows sperm to pass but traps the larger blastocyst, leading to an ectopic implantation. Rupture typically occurs between 6–10 weeks, causing massive intraperitoneal hemorrhage and hemorrhagic shock. **Why other options are incorrect:** * **Option B (Septic Shock):** While shock is present, septic shock usually follows an infected abortion or pelvic inflammatory disease and is characterized by high-grade fever, foul-smelling vaginal discharge, and leukocytosis, rather than sudden collapse following amenorrhea. * **Option C (DIC):** DIC is a secondary consumptive coagulopathy. While it can occur as a complication of severe hemorrhage or abruptio placentae, it is not a primary diagnosis for sudden shock at 8 weeks of gestation. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of ectopic pregnancy:** Ampulla of the fallopian tube. * **Most common site of rupture:** Isthmus (occurs earlier, around 6–8 weeks, due to narrow lumen). * **Risk Factors:** History of PID/Tubal TB (strongest in India), previous ectopic pregnancy, tubal surgery, and IUCD use. * **Classic Triad:** Amenorrhea, abdominal pain, and vaginal bleeding (present in only 50% of cases). * **Gold Standard Investigation:** Transvaginal Ultrasound (TVUS) + Serum β-hCG (Correlation of the "Discriminatory Zone").

Q: Which of the following are causes of polyhydramnios?

Diabetes mellitus, esophageal atresia, anencephaly. **Explanation:** Polyhydramnios is defined as an excess of amniotic fluid (Amniotic Fluid Index >25 cm or Single Deepest Pocket >8 cm). The volume of amniotic fluid is a balance between production (primarily fetal urine) and removal (primarily fetal swallowing). **Why Option D is Correct:** * **Diabetes Mellitus:** Maternal hyperglycemia leads to fetal hyperglycemia, causing **osmotic diuresis** and fetal polyuria. * **Esophageal Atresia:** This creates a mechanical GI obstruction, preventing the fetus from **swallowing** and absorbing amniotic fluid. * **Anencephaly:** This causes polyhydramnios via two mechanisms: the absence of the swallowing reflex and **transudation** of fluid from the exposed meninges into the amniotic cavity. **Why Other Options are Incorrect:** * **Renal Agenesis (Options A, B, C):** This is a classic cause of **oligohydramnios**. Since fetal urine is the primary source of amniotic fluid in the second and third trimesters, the absence of kidneys leads to a severe fluid deficiency (Potter’s sequence). * **Preeclampsia (Option B):** This is typically associated with placental insufficiency and fetal growth restriction, which leads to redirection of blood flow away from the fetal kidneys, resulting in **oligohydramnios**. **NEET-PG High-Yield Pearls:** * **Most common cause:** Idiopathic (approx. 50-60%). * **Most common maternal cause:** Diabetes Mellitus. * **Congenital anomalies:** Neural tube defects (anencephaly) and GI obstructions (duodenal atresia - "double bubble" sign) are high-yield associations. * **Complications:** Preterm labor (due to uterine overdistension), cord prolapse (upon ROM), and postpartum hemorrhage (uterine atony).

Q: In a patient with preeclampsia, all of the following drugs can be used in treatment EXCEPT?

Enalapril. **Explanation:** The management of hypertension in pregnancy requires drugs that are effective for the mother while being safe for the developing fetus. **Why Enalapril is the Correct Answer:** Enalapril is an **ACE Inhibitor (ACEI)**. ACE inhibitors and Angiotensin Receptor Blockers (ARBs) are strictly **contraindicated** in pregnancy (FDA Category D). Their use, especially in the second and third trimesters, is associated with **fetal renal dysgenesis**, oligohydramnios (due to decreased fetal urine production), pulmonary hypoplasia, intrauterine growth restriction (IUGR), and calvarial hypoplasia. **Analysis of Incorrect Options:** * **Labetalol (Option A):** A combined alpha and beta-blocker. It is currently considered the **first-line** drug for both chronic hypertension and acute hypertensive emergencies in pregnancy due to its rapid onset and safety profile. * **Methyldopa (Option B):** A centrally acting alpha-2 agonist. It has the longest track record of safety in pregnancy and is often the preferred drug for long-term management of **chronic hypertension** in pregnant patients. * **Hydralazine (Option C):** A direct vasodilator. It is traditionally used intravenously for the management of **acute hypertensive crises** (Severe Preeclampsia/Eclampsia) when rapid blood pressure reduction is required. **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice (DOC) for Acute Hypertensive Crisis in Pregnancy:** IV Labetalol (Hydralazine is an alternative). * **DOC for Chronic Hypertension in Pregnancy:** Oral Methyldopa. * **Target BP in Preeclampsia:** Aim to maintain Systolic BP between 140–150 mmHg and Diastolic BP between 90–100 mmHg. * **Other Contraindicated Drugs:** Diuretics (may compromise placental perfusion), Nitroprusside (risk of fetal cyanide poisoning), and Atenolol (associated with fetal bradycardia and IUGR).

Q: Which is the commonest type of ectopic pregnancy presenting with rupture?

Isthmic. **Explanation:** The correct answer is **Isthmic (Option A)**. The site of ectopic pregnancy significantly influences the timing and likelihood of rupture based on the anatomical diameter and distensibility of the Fallopian tube. 1. **Why Isthmic is correct:** The **isthmus** is the narrowest part of the Fallopian tube with a thick, muscular wall and minimal distensibility. Because the lumen is so small, the growing embryo quickly outgrows the space, leading to **early rupture**, typically between 6 to 8 weeks of gestation. While the ampulla is the most common site for ectopic pregnancy overall, the isthmus is the site most likely to present with an acute rupture. 2. **Why other options are incorrect:** * **Ampulla (B):** This is the most common site for ectopic pregnancy (approx. 70%). However, because the ampulla is wider and more distensible, it often results in a "tubal abortion" or a delayed rupture (8–12 weeks) rather than an early, acute rupture. * **Interstitial (C):** This is the most dangerous site. Because it is surrounded by thick myometrium, it can distend significantly, rupturing late (12–16 weeks). When it does rupture, it causes massive, life-threatening hemorrhage. * **Infundibular (D):** This is the least common site and usually results in tubal abortion into the peritoneal cavity. **High-Yield NEET-PG Pearls:** * **Most common site of Ectopic Pregnancy:** Ampulla. * **Most common site of Ruptured Ectopic:** Isthmus. * **Most common site of Tubal Abortion:** Ampulla. * **Site with highest mortality/most severe hemorrhage:** Interstitial (Cornual). * **Classic Triad:** Amenorrhea, abdominal pain, and vaginal bleeding (present in only 50% of cases).

Question 1

A 24-year-old patient presents at 18 weeks of pregnancy with a previous history of a child with Down syndrome. What is the most appropriate next step?

Accepted Answer

Amniocentesis

Answer

Triple test

Answer

Chorionic villous biopsy

Answer

Cordocentesis

Question 2

Which of the following is a potential candidate for a high risk of Gestational Diabetes Mellitus (GDM)?

Accepted Answer

Unexplained perinatal loss

Answer

Young primigravida

Answer

Presence of oligohydramnios

Answer

Previous low birth weight baby

Question 3

A 32-year-old female presents with 8 weeks of amenorrhea, signs of shock, and a past medical history of tuberculosis. What is the most likely diagnosis?

Accepted Answer

Ruptured ectopic pregnancy

Answer

Septic shock

Answer

Disseminated intravascular coagulation (DIC)

Answer

None of the above

Question 4

Which of the following are causes of polyhydramnios?

Accepted Answer

Diabetes mellitus, esophageal atresia, anencephaly

Answer

Diabetes mellitus, renal agenesis, anencephaly

Answer

Preeclampsia, renal agenesis, anencephaly

Answer

Esophageal atresia, renal agenesis, anencephaly

Question 5

Cervical pregnancy is confirmed by the presence of?

Accepted Answer

Histology showing the presence of villi inside the cervical stroma

Answer

Gestational sac below the internal os

Answer

Intractable bleeding following evacuation or expulsion of products

Answer

Painless bleeding

Question 6

A 22-year-old woman presents with a 2-hour history of acute abdominal pain and vaginal bleeding. Her vital signs are normal. Physical examination reveals blood oozing from the vaginal opening. Laparotomy shows an enlarged right fallopian tube with hemorrhage and rupture. What is the most likely cause of hemorrhage in this patient?

Accepted Answer

Ectopic pregnancy

Answer

Choriocarcinoma

Answer

Infarcted tubal polyp

Answer

Intramural leiomyoma

Question 7

In a patient with preeclampsia, all of the following drugs can be used in treatment EXCEPT?

Accepted Answer

Enalapril

Answer

Labetalol

Answer

Methyldopa

Answer

Hydralazine

Question 8

A pregnant female with a past history of embolism in puerperium requires medical management in her next pregnancy to avoid recurrence. What is the recommended management?

Accepted Answer

Anticoagulation therapy with warfarin initiated after delivery.

Answer

Prophylaxis with warfarin starting at 10 weeks gestation.

Answer

The risk of thromboembolism increases by 12% in the next pregnancy.

Answer

No specific medical management is required.

Question 9

A young lady presents with 6 weeks of amenorrhea, nausea, vomiting, and severe abdominal pain. Her BP is 100/80 mm Hg. Examination reveals a 5 x 5 cm adnexal mass. What is the plan of management?

Accepted Answer

Immediate laparoscopic surgery

Answer

Send beta-hCG

Answer

Methotrexate

Answer

IV fluids, NPO, and observation for 4-5 days

Question 10

Which is the commonest type of ectopic pregnancy presenting with rupture?

Accepted Answer

Isthmic

Answer

Ampulla

Answer

Interstitial

Answer

Infundibular

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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